Minimally Invasive Single Site (MISS) surgery is a better terminology to explain the novel concept of scarless surgery, which is increasingly making its way into clinical practice. But, there are some difficulties. We review the existing technologies for MISS surgery with regards to single-port devices, endoscope and camera, instruments, retractors and also the future perspectives for the evolution of MISS surgery. While we need to move ahead cautiously and wait for the development of appropriate technology, we believe that the “Ultimate form of Minimally Invasive Surgery” will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery, complimented by technological innovations from the fields of robotics and computer-assisted surgery.

“Minimal invasive single-site surgery in colorectal procedures: Current state of the art.”

Diana, M., P. Dhumane, et al. (2011).

Journal of Minimal Access Surgery 7(1): 52-60.

Background: Minimally invasive single-site (MISS) surgery has recently been applied to colorectal surgery. We aimed to assess the current state of the art and the adequacy of preliminary oncological results. Methods: We performed a systematic review of the literature using Pubmed, Medline, SCOPUS and Web of Science databases. Keywords used were “Single Port” or “Single-Incision” or “LaparoEndoscopic Single Site” or “SILSTM” and “Colon” or “Colorectal” and “Surgery”. Results: Twenty-nine articles on colorectal MISS surgery have been published from July 2008 to July 2010, presenting data on 149 patients. One study reported analgesic requirement. The final incision length ranged from 2.5 to 8 cm. Only two studies reported fascial incision length. There were two port site hernias in a series of 13 patients (15.38%). Two “fully laparoscopic” MISS procedures with preparation and achievement of the anastomosis completely intracorporeally are reported. Future site of ileostomy was used as the sole access for the procedures in three studies. Lymph node harvesting, resection margins and length of specimen were sufficient in oncological cases. Conclusions: MISS colorectal surgery is a challenging procedure that seems to be safe and feasible, but the existing clinical evidence is limited. In selected cases, and especially when an ileostomy is planned, colorectal surgery may be an ideal indication for MISS surgery leading to a no-scar surgery. Despite preliminary oncological results showing the feasibility of MISS surgery, we want to stress the need to standardize the technique and carefully evaluate its application in oncosurgery under ethical committee control.

“Evaluation of a novel single-port robotic platform in the cadaver model for the performance of various procedures in gynecologic oncology.”

“Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery.”

Fader, A. N., K. L. Levinson, et al. (2011).

Journal of Minimal Access Surgery 7(1): 71-77.

Review Objective: To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology. Recent Findings: Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript. Conclusions: LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.

“Where do we really stand with LESS and NOTES?”

Gettman, M. T., W. M. White, et al. (2011).

European Urology 59(2): 231-234.

“SPIDER Surgical System for Urologic Procedures With Laparoendoscopic Single-Site Surgery: From Initial Laboratory Experience to First Clinical Application.”

Haber, G. P., R. Autorino, et al. (2011).

European Urology.

This case study describes our initial laboratory experience using the SPIDER surgical system (TransEnterix, Morrisville, NC, USA) for laparoendoscopic single-site surgery (LESS) urologic procedures and reports its first clinical application. The SPIDER system was tested in a laboratory setting and used for a clinical case of renal cyst decortication. Three tasks were performed during the dry lab session, and different urologic procedures were conducted in a porcine model. The time to complete the tasks and penalties were registered during the dry lab session. Perioperative outcomes and subjective assessment by the surgeons were registered. The surgeons had a positive experience with the SPIDER system, with a mean overall score of 3.6 (on a scale of 1-5). The surgeons were able to gain proficiency in performing tasks regardless of their level of expertise. The highest scores recorded were for ease of device insertion, instrument insertion and exchange, and triangulation. The lowest scores were for retraction. During the clinical case, the platform provided good triangulation without instrument clashing. However, retraction was challenging because of the lack of strength and precise maneuverability with the tip of the instruments fully deployed. The SPIDER system offers intuitive instrument maneuverability and restored triangulation without external instrument clashing. Further refinements are awaited to define its role in the urologic LESS armamentarium.

“Single-incision laparoscopic myomectomy.”

Jackson, T. R. and J. I. Einarsson (2011).

Journal of Minimal Access Surgery 7(1): 83-86.

Laparoscopic myomectomy is a minimally invasive surgical option for the treatment of uterine leiomyomas. Single-incision laparoscopy is a relatively new concept that has potential in gynaecological surgery although the technical challenges of single-incision access have limited the widespread use of the technique. The use of intracorporeal suturing is a significant component of the learning curve for laparoscopic myomectomy and presents an even greater challenge with single-incision laparoscopic myomectomy. This article describes a surgeon’s approach to single-incision laparoscopic myomectomy.

“Selection of a Port for Use in Laparoendoscopic Single-siteSurgery.”

Khanna, R., M. A. White, et al. (2011).

Current Urology Reports.

Laparoendoscopic single-site surgery (LESS) is a novel technique that aims to perform abdominal surgery through a single incision. Various access techniques and ports exist. This review will attempt to describe the currently available ports as well as highlight their advantages and disadvantages.

Academic Journal of Second Military Medical University 31(12): 1349-1352.

Objective: To summarize our experience and operative techniques of transumbilical laparo-endoscopic single-site partial nephrectomy (TLSPN). Methods: TLSPN was performed on two patients for the right kidneys in August and September of 2009. Results: The operation was successfully done in both cases, with an additional trocar of 5 mm to retract the liver. The operation time was 255 min and 240 min; the time periods of renal artery occlusion were 48 min and 40 min; and the intraoperative blood losses were 100 ml and 50 ml. None of the patients received blood transfusion or antalgic. The drainage was removed 9 days and 5 days after operation, and the postoperative hospital stays were 13 and 12 days. Conclusion: TLSPN is a safe and effective method with less trauma. However, special instruments are needed for the procedure, and the suture and knotting are somewhat difficult. An assistant trocar is needed for the procedure for the right kidney.

Scarless surgery is the Holy Grail of surgery and the very raison d′etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a ′scarless′ effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.

Single-incision laparoscopic surgery (SILSTM) is rapidly becoming the focal point of attraction for early adopters of minimally invasive surgery nationwide. Having achieved a rapid crossover to the realm of advanced surgical procedures, SILSTM has shown remarkable versatility and adaptability, making it no longer limited to basic laparoscopic procedures. We report our experience performing laparoscopic placement of gastric bands with an emphasis on comparison of the singleincision laparoscopic approach with the conventional multiport laparoscopic approach. From December 2008 to September 2009, 27 patients underwent laparoscopic placement of an adjustable gastric band at Michigan State University/Kalamazoo Center for Medical Studies. This included 15 patients who underwent single-incision laparoscopic gastric banding and 12 patients who underwent conventional multiport laparoscopic gastric banding procedures. The overall pain score was found to be significantly less in the SILS group than that for the conventional multiport laparoscopic gastric banding group with a statistically significant P value of 0.012. The operating time was found to be significantly less in the multiport group with a P value of 0.000. Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant. Single-incision laparoscopic gastric banding is associated with significantly less overall postoperative pain than the conventional laparoscopic approach; in addition, it provides improved cosmetic outcome despite a modest increase in operative time.

“Urological applications of single-site laparoscopic surgery.”

Symes, A. and A. Rane (2011).

Journal of Minimal Access Surgery 7(1): 90-95.

Single-port, single-incision laparoscopy is part of the natural development of minimally invasive surgery. Refinement and modification of laparoscopic instrumentation has resulted in a substantial increase in the use of laparoendoscopic single-site surgery (LESS) in urology over the past 2 years. Since the initial report of single-port nephrectomy in 2007, the majority of laparoscopic procedures in urology have been described with a single-site approach. This includes surgery on the adrenal, ureter, bladder, prostate, and testis, for both benign and malignant conditions. In this review, we describe the current clinical applications and results of LESS in Urological Surgery. To date this evidence comes from small case series in centres of excellence, with good results. Further well-designed prospective trials are awaited to validate these findings.

Abstract Techniques that attempt to further reduce the morbidity and improve cosmesis of laparoscopic surgery have particularly generated interest. Since its initial urologic description in 2007, there has been a surge of interest in laparoendoscopic single-site surgery, which is now an emerging technique within the field of minimally invasive urologic surgery. This report describes a preliminary experience with single-site video endoscopic inguinal lymphadenectomy (SSVEIL) compared with conventional video endoscopic inguinal lymphadenectomy (VEIL) on inguinal nodes management in a 45-year-old man with pT(2) grade 2 squamous cell penile carcinoma and impalpable inguinal nodes. VEIL with saphenous vein preservation in the left leg and SSVEIL on the other side presented no difference concerning operative time (100 vs 120 min), blood loss (50 mL), drainage volume, number of nodes retrieved (8), pain, and oncologic outcome. The patient had an uneventful postoperative course, was discharged 12 hours after the procedure, and preferred the aesthetic result of SSVEIL. Further refinements in technology will likely alleviate many of the persistent technical problems. Additional rigorous comparison studies are needed to evaluate the true benefits of the technique and the extent of its clinical application, mainly oncologic results, before the widespread adoption of SSVEIL. Ultimately, advance breakthroughs in fields of in-vivo instrumentation, robotics, and purpose-built robotic platforms will bring its potential to full clinical realization.

“Motion planning and coordination for robot systems based on representation space.”

Su, J. and W. Xie (2011).

IEEE Trans Syst Man Cybern B Cybern 41(1): 248-259.

This paper proposes a general motion planning and coordination strategy for robot systems. The representation space (RS) of a robot system is constructed to describe the distributions of system attributes. The reachable area in the RS, denoting the attribute set that the system can be of, indicates the system’s ability to accomplish tasks. Moreover, it also describes the influences of the internal and external constraints on the system’s capability. Task realization is transformed to finding a trajectory in the RS for the system attributes to transit along under constraints. Meanwhile, the realizable conditions of a prescribed task by the robot system of specific configurations are discussed. If the task is realizable, the optimal strategy for task execution could further be figured out. Otherwise, it could be transformed to be realizable via task reassignment or system reconfigurations so that a connected path could be found for the transition of the system attributes from the starting point to the goal in the RS. The proposed scheme contributes to designing, planning, and coordination of the robotic tasks. Experiments on path planning of a robot manipulator and formation movement of a multirobot system, as well as coordination of a mobile manipulator system, are conducted to show the validity and generalization of the proposed method.